We provide comprehensive care to our patients.
Today's Date* (YYYY-MM-DD)
Birth Date (YYYY-MM-DD)
Place of Employment
Emergency Contact not living with you
Name of Physician
Address of Physician
Date of last Physical Exam(YYYY-MM-DD)
Are your teeth experiencing any discomfort or pain at this time?
If Yes then explain
Do you frequently get food caught between any teeth? Where?
If Yes then explain
Are you interested in
Teeth WhiteningStraightening of Teeth (Invisalign)Smile transformation
Please select if you have or have you had any of the following
ClenchingGrindingJaw PainPopping SoundsLimited OpeningLockingSensitivity
Are you in good general health?
List ALL Medical Conditions and Allergies
Please list ALL current medications, dosage and reason for usage
Have you been hospitalized or had any serious illness or operation ever?
If yes then When and What
Have you tested positive for COVID-19? If Yes, what was the date you tested positive?YesNo
Please select if you have had an allergic reaction or reacted to any of the following
Local anaestheticsAntibioticsPenicillinSulfa drugsBarbituratesSedativesAspirinTylenolSleeping PillsCodeineDemerolLatex (eg. rubber gloves)
Please select if you have had any of the following
Cardiac PacemakerTuberculosisSinusitisEmphysemaChronic BronchitisAsthmaSinus troubleStomach ulcersHepatitisHIVJaundiceDiabetesThyroid troubleAnemiaSickle Cell diseaseBlood disordersHemophiliaGlaucoma
Do you have chest pain after exercise?
Please select if have ever had
EpilepsyFainting SpellsSeizuresEmotional disturbance
Are you currently under physician’s care for anything?
Is there any family history of blood disorders?
Have you had abnormal bleeding after any surgery, extraction or trauma?YesNo
Have you ever had a blood transfusion? When?
Please select if you have or have you ever had?
ArthritisInflammatory RheumatismBone InfectionOsteoporosisKidney troubleVenereal diseaseExposure to HIV virusAIDSTumorChemotherapyRadiation therapyCancer
Do you have artificial joints? What and date of placement:
Do you smoke or use tobacco?
If Yes. How many times per day?
Do you drink alcohol?
If Yes. How much in a week?
Do you consume any recreational substances?
If Yes. What and how often?
Are you pregnant or nursing?
If Yes. How many weeks?
Is there anything in your medical and dental history that we have not specifically asked about that we should be
made aware of? If so, please explain.
I hereby authorize and request the performance of dental services for myself or any of my dependents. I also give my consent to the advisable and necessary dental procedures, medications, or anesthetics to be administered by the attending dentist or by his supervised staff for dental treatment or diagnostic purposes. These records may include study models, photographs, or x-rays. I understand and acknowledge that I am financially responsible for the services provided for myself
or any of my dependents, regardless of the insurance coverage. I also understand that the treatment estimate presented to me is only an estimate and occasionally, the need may arise to modify treatment. I believe the information given in the previous pages of the medical and dental history to be true to the best of my knowledge.
326 Queens Ave London, ON N6B 1X4
Phone: (519) 439-6491